HomeMy WebLinkAboutMINUTES - 06172008 - HSD.1 TO: BOARD OF SUPERVISORS �t1� sE L ,o� Contra
FROM: William Walker, M.D., Director �� _ Is Costa
Health Services Department �o
Sra cotiK C t
DATE: June 17, 2008 County
SUBJECT: Report on Nursing Issues Faced by the Contra Cost Regional Medical Center
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION(S): CONSIDER accepting a report from the Health Services
Department on the national, state, and local nursing shortage, implications of the nursing
shortage for the Contra Costa Medical Center, bedside care, and medication safety teams, as
recommended by the Health Services Director.
FISCAL IMPACT: No fiscal impact, informational only.
BACKGROUND/REASON(S) FOR RECOMMENDATION(S): The overall aim is to use
multidisciplinary teams to drive transformation change in patient care delivery.
This presentation will give background on the nursing crisis; demonstrate replication and
expansion on the work of others to support improvements that affect organizational culture in
the hospital setting.
Healthcare is in a state of crisis across our nation. This, coupled with the impending nursing
shortage and regulatory pressures creates the tension and overall awareness for the need to
change.
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VOTOF SUPERVISORS: I HEREBY CERTIFY THAT THIS IS A TRUE
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OF SUPERVISORS ON THE DATE SHOWN.
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ATTESTED
CONTACT:Lisa Massarweh JOHN CULLEN,CLERK OF THE
370-5121 BOARD OF SUPERVISORS AND
COUNTY ADMINISTRATOR
CC: Health Services Department
County Administrator's Office 0B ��Ty
Page 2 of 8
Researchers studying reliability have concluded if health care statistics were taken to the
airline industry, we would expect to see failure rates comparative to two jumbo jet crashes
every three days. The quality crisis is comprised of avoidable errors, overuse of unnecessary
services, under utilization of necessary services, and inexplicable variation. Medication errors
alone are the most common type of error in health care and estimated that one medication
error occurs per patient per day of hospitalized care (Leape, et al., 1995). Forty-five percent
of adults do not receive recommended chronic and preventative care, and 30% seeking care
for acute problems receive treatment that is contraindicated (Schuster et al., 1998). There is
the beginning of an awakening from blaming "bad apples" and departments charged with
assuring quality to a systems view of creating an environment of safety. There is a momentum
across the nation, a realization that our current structures are broken, and glimmers of hope
driven by successes in the 100K Lives campaign, and more regulatory coordination around
patient safety that a new methodology is on the horizon.
The IOM has reported medical error rates in hospitalized patients account for as many as
98,000 deaths per year. The first report To Err Is Human focused on problems in health
systems rather than individuals; it concluded that fundamental changes in the way care is
delivered are essential. The subsequent IOM report Crossing the Quality Chasm took up the
challenge of suggesting how the system should be redesigned. The identified aims for quality
improvement concluded that care should be safe, effective, patient-centered, timely, efficient,
and equitable. Threats to patient safety can be found in organizational management
practices, workforce deployment, work design, and organizational culture. To drive deep and
lasting change will require work on all fronts. The Transforming Care At The Bedside is one
method to address needed change at the point of acute care-the bedside.
With the Institute of Medicine's report: To Err Is Human: Building a Safer Health System (IOM,
2000), attention was centered squarely on safety in our hospitals with regard to a national
agenda for patient safety. This work focused attention on political, payment, regulatory,
accreditation and other external factors. Following the first IOM report came Crossing the
Quality Chasm:A New Health System for the 295 Century (IOM, 2001). This work focused on
health care delivery including the patient's experience, functioning at the unit as well as the
organization, and other external factors that affect care delivery such as health policy. The
estimate of as many 98,000 needless deaths a year caught the nation's attention. This
seminal body of work, along with the challenge from the Institute for Health Care
Improvement's campaign to save 100K lives (IHI, 2004-6) ignited a new excitement in care
delivery with measurable results.
Recognizing the key role of nurses in patient safety, the U.S. Department of Health and
Human Services' Agency for Healthcare Research and Quality (AHRQ) asked the IOM to
conduct another study, Keeping Patients Safe: Transforming the Work Environment of Nurses
(IOM, 2004). The focus of this work was to identify key aspects of the work environment as
well as identify potential improvements in health care working conditions that likely would
increase patient safety. Nurses were identified as central in the role of patient safety.
Licensed nurses (R.N's and L.V.N's) make up approximately 54% of all U.S. health care
workers. Issues addressed involved work culture, physical environment, workplace_systems,
and communication barriers. Meanwhile, the American Association of Critical Care Nurses
commissioned work to focus solely on components that are essential to healthy work
environments, and published Standards for Establishing and Sustaining Healthy Work
Page 3 of 8
Environments (AACN, 2005). These standards are meant to engage dialogue about current
work environment realities and to build the relations within these environments with a
realization that unhealthy work environments lead to medical errors, ineffective health care
delivery, and worker stress.
This project will provide a structure to guide the way of new models of care delivery while
engaging the workforce and creating a learning organization. One of the larger goals of the
hospital and health centers at Contra Costa County is to become the employer of choice.
Work in reliable design processes, a system's perspective, identification and elimination of
waste, patient-centeredness, and engagement of staff provide pillars upon which to build.
Nursing is inseparably linked to patient safety yet the typical work environment of nurses is
characterized by many serious threats to that fundamental goal. Linda Aiken, a leading
researcher in nursing workforce indicates that for each 10% of higher entry level
(Baccalaureate degree) into nursing practice produces a 5% reduction in mortality; and a 7%
mortality increase is realized for each one patient added to the Registered Nurse's workload
(hftp://www.medscape.com/viewarticle/462039, last accessed 2/17/2007). Threats are found
in organizational management practices, workforce deployment practices, work design, and
organizational culture. To drive deep cultural change and transform care delivery occurs one
step at a time. The first step is the realization that the system is broken. We must then
provide a vision and path for change and communicate that vision and pathway repeatedly to
all corners of the organization. The IHI work on transforming medical-surgical care, along with
work environment and safety principles will guide this project. Data on set performance
indicators will be analyzed and communicated to all levels of the organization including the
governing body and community at large.
Change efforts will center around methods to deliver safe, reliable care including reduction in
harm from falls, adverse events, and nosocomials; engaging staff and patients to be drivers of
change; and looking to other industries such as airlines and Toyota production for efficiency
models.
Initially three hospitals were recruited to participate in the combined work between the
Institute for Health Care Improvement and the Robert Wood Johnson Foundation to embrace
the Transforming Care at the Bedside initiative. These prototype facilities became the
learning ground for a larger effort. Currently with 50 participating hospitals, spread and
sustainability of addressing the care experience of patients in hospital medical-surgical units,
as well as the experience of health care professionals and the work environments in which the
care givers function is driving change.
By joining the Institute for Healthcare Improvement's Transforming Care At The Bedside
(TCAB) collaborative and adding to the replication of this project in a safety-net hospital, front-
line staff, including unit leaders and union leadership, will be engaged in creating, testing, and
standardizing care processes created by the IHI and drive whole-system change with the
following aims on one medical unit:
• Reducing adverse events to less than 1 per 1,000 patient days
• Reducing falls to less than 1 per 1,000 discharges on the unit
• Creating a retention-focused culture with a staff turnover rate of less than 5% annually
Page 4 of 8
• Increasing caregiver time at the bedside to greater than 75% of their time; significantly
increase value-added activities
• Improving patient willingness to recommend the unit to 100% "top box" responses
• Enhancing patient satisfaction with communication and care coordination to "top box"
responses
• Increasing clinical care reliability to 98% for top diagnosis or condition on unit
• Increasing staff satisfaction
Each of the above aims has change methodologies supported by the IHI. Staff leaders will
have the necessary backing of administration to implement and evaluate small tests of
change using multiple cycles of the Plan, Do, Study, Act (PDSA) improvement model.
Assuming the project aims are met in the medical unit, the work will next spread to the
surgical unit of the hospital, and then ultimately the entire facility.
Located in northern California, and serving a population of 1,000,000 residents, Contra Costa
Health Services consists of an integrated health delivery system and was the first federally
qualified, publicly sponsored health plan in the country. Contra Costa Health Division is one
entity of the county structure and is governed by an elected county board of supervisors. The
department is comprised of a 166-bed acute care facility, eight ambulatory health centers,
public health, mental health, alcohol and other drugs, hazardous materials, emergency
medical services, detention health, and health plan. The medical center has approximately
8,000 discharges annually. It is also a teaching facility for a family practice residency
program, as well as provider for clinical instruction of nursing and ancillary care students.
The ambulatory care side services approximately 400,000 visits annually.
As the safety-net for Contra Costa County, the mission of Contra Costa Health Services is to
provide health care for all people, paying special attention to those who are most vulnerable
to health problems. This health system provides the physical facilities and system structures
that reach into a medically underserved community and provides services to those who
otherwise may be without care.
Market Characteristics and Trends
With eight acute care facilities consisting of a total of 1,488 in-patient beds available in the
county, Contra Costa Regional Medical Center is the only county owned/operated acute care
facility. This distinction is important, as Contra Costa Health Services will likely become in more
demand. County economic data reveal both growing unemployment rates as well as poverty
rates from 2000 to 2005. Unemployment rates of 3.5% in 2000 grow to 4.8% in 2005 and the
poverty rate grows for 7.6% to 8.1% (http://www.labor.ca.gov/cedp/pdf/ContraCosta.pdf, last
accessed 2/4/2007). The uninsured rate for Contra Costa County is at 14.7% of residents
between the ages of 0-64 for all or part of the year during the last twelve months
(http://www.healthpolicy.ucla.edu, last accessed 2/17/2007).
Population projections for Contra Costa County through the year 2050
(hftp://www.dof.ca.gov/HTML/DEMOGRAP/ReportsPapers/Projections/P1/P1.asp, last
accessed 2/4/2007) estimate a steady growth rate of nearly 52% or 1.8 million residents.
Page 5 of 8
More specifically, the break down by race indicate the Hispanic population growing from 18%
in the 2000 census to a projected 40% in 2050, an Asian population growing from 1% to 22%
and a African American population growth from 9.2% to 10.6%. Whites become the minority
prior to the earliest projections in 2010. This is significant when analyzing the 2004 health
indicators of Contra Costa County. The Hispanic population of Contra Costa County has a
statistically significantly higher death rate from diabetes than the county as a whole. African
Americans in Contra Costa County statistically have more death from heart disease, cancer,
stroke, diabetes, and homicide than others in the county.
Market Environment
In work settings, there is certainly no more a complex environment than that of the health care
arena. This ever-changing environment is also coupled with a national and international
shortage of Registered Nurses to create a "perfect storm" for providing skilled health care to
society as a whole. To further worsen the situation, those most in need of care frequently
have a more difficult time of accessing services. California currently ranks next to last in the
number of Registered Nurses (RN) per capita. By 2030 Northern California is forecasted to
have the greatest share of unfilled RN positions with a nearly 40% vacancy rate (Spetz,
2006).
As the largest health care professional group in the United States, nurses have the most
direct encounters with patients at every level of the health care system. While health care
shortages have occurred in the past, the current nursing shortage is uniquely serious.
Coupled with supply and demand issues, an aging workforce, and wide career opportunities
for youth, access to healthcare may be limiting, and even more so for the most vulnerable
patients.
As the population grows older, demands on health care professionals increase. The baby
boom of 1946-1964 was immediately followed by an 11-year baby bust, when the birth rate
fell to a low of 146 births per 1,000. This generation is now creating the smallest pool of
entry-level workers since the 1930's. U.S. Census Bureau projections show the boomer-to-
buster ratio may fall from 1.74 in 1990 to 1.6 in 2010 and a shortage of more than one million
Registered Nurses is predicted. Technological advances, heightened patient acuity, and
shorter lengths of stay also put higher demands on nurses (Adams, 1999). These demands
are compounded by the dwindling supply of registered nurses. Buerhaus, Staiger, &
Auerback (2000) found that thirty-five percent fewer full-time registered nurses are observed
today when compared to similar age groups of RNs entering the workforce 20 years ago.
They also reported that within 10 years, 40 percent of working RNs will be 50 years or older.
When this population retires, the supply of working RNs is projected to be 20 percent below
requirements by the year 2020. Additionally, young adults are choosing higher paying jobs in
professions other than nursing. Practicing nurses are moving out of full-time positions or they
are moving away from bedside patient care (Navidjon, 2000). The American Association of
Colleges of Nursing (2000) found that enrollment in all basic nursing education programs has
fallen by approximately five percent each year since 1995. The California Board of Registered
Nursing commissioned UCSF (Spetz & Dyer, 2005) to study the demands on this workforce.
Findings indicate that the California RN shortage will worsen each year through 2030 and that
the only solution to help mitigate the deficit is to continue efforts to increase the number of
graduates from California nursing programs.
Page 6 of 8
While the forecast for nursing services in general are bleak, for those in underserved
populations, the situation worsens. As reported in the master plan for the California nursing
workforce (2005), with escalation of the nursing shortage, the impact will be especially felt in
out-of-hospital settings such as home health, long term care, and ambulatory settings. These
areas of service will significantly impact vulnerable populations such as the elderly and
underserved. A study conducted by Princeton Survey Research Associates found that, in
addition to decreased access to healthcare, Hispanics, Asians and blacks are still more likely
than whites to have difficulty communicating with their doctors about their health issues (Race
and Health, 2004). Language barriers were not the only concerns regarding difficulty
communicating with providers. Non-English speaking patients reported not fully
understanding their doctors and reported feeling as though their doctors weren't listening to
them. Many of the study's participants felt they would receive better healthcare if they were
white. Although recognition of unequal health outcomes have been readily documented for
decades, racial disparities in healthcare remain "chronic" according to the American Medical
Association (AMA), with racial minorities benefiting the least from what the AMA has
described as "marked by advances in medicine and health care that most would have
classified as belonging in the realm of science fiction." Thirty-one percent of minority adults,
ages 18-64, do not have insurance, compared with 14 percent of white adults in the same age
group. (Commonwealth Fund Study, 1995) Minority adults report more problems with
receiving health care. Forty percent say they have "a major problem with having to pay too
much for care," compared to 26 percent of white adults. (Schoen and DesRoches, 2000)
Further, low-income persons, regardless of race, spend more out-of-pocket income--about
seven to eleven percent--on medical expenses than higher income Americans who typically
only spend about 1-2 percent of their income on medical care. (Cantave, C. and Harrison, R.,
2001) The infant mortality longstanding disparity has increased from 1.6 times the rate for
whites in 1950 to 2.2 times the rate in 1991. (Mathews, Menacker, and MacDorman, 2004)
Black women are twice as likely as white women to obtain late or no prenatal care; Hispanic
women are three times as likely to obtain inadequate or no prenatal care than non-Hispanic
white women; and American Indian women are more likely than either white or black women
to obtain late or no prenatal care at all (American Medical Association, 2003).
Morbidity costs
Increasing RN time at the bedside by thirty minutes, has been associated with a decrease of
adverse post-surgical events by 4.5% for urinary tract infections, 4.2% for pneumonia, 2.6%
for thrombosis, and 1.8% for pulmonary compromise (Kovner, C, Gergen, PJ, 1998).
On the basis of a Barker et al. (2002) study and assuming a patient in the hospital receives 10
doses per day, a typical patient would be subject to one administration error per hospitalized
day. The total cost associated with preventable adverse drug events after adjusting for
patient co-morbidities and case mix was a cost of$5,857 (Bates et al., 1997). To actualize
these numbers above, the average number of medication errors per month (13.5) is cost
calculated above.
A University of Pennsylvania study (Aiken, LH, Clarke, SP, Sloane, DM, Sochalaski, J, Silber,
JH, 2002) further revealed that each additional patient assigned to a nurse's patient load,
resulted in a 7% increase in mortality, 7% increased failure to rescue, 15% increase in job
dissatisfaction, and a 23% increase in burnout. Of those studied (n=10,000), 43% were
Page 7 of 8
burned out and emotionally exhausted. Conversely, lower nurse-to-patient staffing ratios are
associated with higher rates of adverse events including nosocomial infections, pressure
ulcers, cardiac and respiratory failure, "failure to rescue," and increased length of stay (Aiken
et.al, 2002; Needleman et al, 2002, Seago, 2001, & Kovner, 2002). Average cost of care for
one urinary tract infection or one case of pneumonia in our institution is estimated at $1,600
each. The cost of care for one case of venous thrombosis is $5,000. The reduction of these
adverse events is actualized above and represented as a cumulative economic value.
Assuming a 5% reduction in length of stay, would realize an annualized savings of $208,050.
References:
Aiken, LH, Clarke, SP, Sloane, DM, Sochalaski, J, Silber, JH, 2002. Hospital nurse staffing,
and patient mortality, nurse burnout and job dissatisfaction. Journal of the American Medical
Association. 288(16). 1987-1993.
American Association of Critical Care Nurses. 2005. Standards for Establishing and
Sustaining Healthy Work Environments
American Medical Association. 2003. Report on racial and ethnic disparities in health care.
Barker KN, Flynn EA, Pepper GA, Bates SW, Miikeal RL. 2002. Medication errors observed in
36 health care facilities. Archives of Internal Medicine. 162(16): 1897-1903.
Bates DW, Spell N, Cullen DJ, Burdick E. Laird N, Peterson LA, Small SD, Sweitzer BJ,
Leape L. 1997. The costs of adverse drug events in hospitalized patients: Adverse drug
events prevention study group. Journal of the American Medical Association. 277(4):307-311.
Buerhaus,P.l., Staiger, D.O., & Auerbach, D.I. (2000). Implications of an aging registered
nurse workforce. Journal of the American Medical Association, 283(22): 2948-54.
Cantave C & Harrison R. 2001. Health insurance coverage
Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System
Institute of Medicine. 2001. Crossing the Quality Chasm:A New Health System for the 21St
Century
Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of
Nurses
Kovner, C, Gergen, PJ. 1998. Image: Journal of Nursing Scholarship. 30(4). 315-321.
Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey R, Ives J,
Laird N, Laffel G, Nemeskal R, Peterson L, Porter K, Servi D, Shea B, Small S, Weitzer B,
Thompson B, Bander Vleit M. 1995. Systems analysis of adverse drug events. Journal of the
American Medical Association, 274(1): 35-43.
Mathews T, Menacker F, & MacDorman. 2004. Infant mortality statistics from the 2002
period linked to birth/infant death data set. Center for Disease Control.
Page 8 of 8
Navidjon, B. (2000). Nursing workforce-facing the future. Health Trustee and Leadership
Institute.
Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke. 2006. Health Affairs. 25(1). 204-211.
Race and health, 2004. Examining racial disparities in healthcare. Police Magazine
Schoen C & DesRoches C. 2000. Role of insurance in providing access to care. Health
Services Research. 35:3.
Schuster MA, et al, 1998. How good is the quality of health care in the United States? Milbank
Q. 67:593.
Seago J. 2001. Nurse staffing, models of care delivery, and interventions. In: Shojania K,
Duncan B, McDonald K, Wachter R, eds. Making Health Care Safer.-A Critical Analysis of
Patient Safety Practices, Evidence Report/Technology Assessment No. 43. Rockville, MD:
AHRQ.
Spetz J. 2006. Regional forecasts of the registered nurse workforce in California. Center for
Workforce Studies: UCSF.
Spetz J & Dyer W. 2005. Forecasts of the registered nurse workforce in California. Center
for Workforce Studies: UCSF.
Tucker, A. & Spear, S. 2006. Operational failures and interruptions in hospital nursing. Health
Research and Educational Trust. 1-20.
VanSlyck & Associates. 2005. Activity study for Contra Costa Regional Medical Center.
Addendum to HSD.1
June 17, 2008
On this day the Board of Supervisorsconsidered accepting a report from the Health
Services Department on the national, state, and local nursing shortage and the
implications of the nursing shortage for the Contra Costa Regional Medical Center,
bedside care, and medication safety teams, as recommended by the Health Services
Director.
Lisa Massarweh, Chief of Nursing; Ori Tzvieli, Attending Physician and Physician
Champion for Transforming Care at the Bedside Team; Karen Finck, Clinical Pharmacist
and Marian Bunce-Houston, Medical/Surgical Clinical Nurse Specialist and Chair of
Transforming Care at the Bedside Team, all from Contra Costa Regional Medical Center
(CCRMC),provided the Board of Supervisors a Power Point presentation on the nursing
crisis of the national, state, and local nursing shortage implications of the nursing
shortage for the Contra Costa Medical Center. (Please see attached copy of Power Point).
The focus of this presentation was to identify key aspects of the work environment as
well as identify potential improvements in health care working conditions that would
increase patient safety.
Supervisor Gioia asked Ms. Massarweh to comment on the status of the Computer
Physician Order Entry(CPOE). He asked if the CCRMC still uses written charts. He
asked the status of where the CCRMC was in this continuum.
Ms. Massarweh said their digital images are scheduled on PAX. She explained written
charts are used with the exception of the Emergency Department. She went on to explain
a *Senate Bill 1875 that was put in to place that recommended technology for medication
administration:
*SB 1875, Speier.Health facilities and clinics:medication-related
errors. Existing law generally regulates the licensure of health facilities
and clinics,as defined,and prescribes the duties of the State
Department of Health Services in this regard.Under existing law,
any person who violates provisions regulating health facilities,or who
willfully or repeatedly violates any rule or regulation adopted
thereunder is guilty of a misdemeanor.
This bill would make it a condition of licensure that these facilities,
with certain exceptions,implement a formal plan,on or before
January 1,2005,to eliminate or substantially reduce
medication-related errors in the facility.
Since a violation of the provisions applicable to health facilities is
a crime,the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the state.
Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason."
Supervisor Gioia asked where hospitals were in the move towards keeping computer
records for patients.
1
Dr. Walker responded recent literatures indicate computer records do not solve all
problems but said it is out there as a goal.
Supervisor Gioia noted more outpatient offices are computerized to record visits to
enable any doctor to access records on any network system, and noted all medications
orders go direct to the pharmacy.
Dr. Walker said with the CCRMC's Meditek system all laboratory work is online.
In conclusion, the Board of Supervisors thanked the CCRMC staff for their presentation
and asked them to return to the Board of Supervisors to let them know how they are
doing.
Supervisor Bonilla asked in terms of the nursing shortage if the CCRMC had a student
volunteer program.
Ms. Massarweh said CCRMC has volunteer system that looks at young people who have
careers in health care and said CCRMC is working with universities and colleges. She
said CCRMC is proposing interested schools of nursing and interested students spend
their entire clinical rotation in CCCRMC with the exception of any experience CCRMC
is unable to provide, that they would work in different frameworks with CCRMC's staff
nurses.
Supervisor Bonilla noted the importance to look at the entire continuum of education and
said she was excited about Cal State East Bay's program of nursing.
Supervisor Piepho asked Dr. Walker the status of the bar-coding technology.
Dr. Walker said it is in CCRMC's strategic plan and said he would keep the Board of
Supervisors informed as and when they get there.
By an unanimous vote with all Supervisors present the Board of Supervisors took the
following action:
ACCEPTED the report from the Health Services Director.
2
i'
My Care at Contra Costa...
i
Patient Care Update
June 17, 2008
Lisa Massarweh,RN,CNO
On Tzvieli,MD
Karen Finck,PharmD
Marianne Bunce-Houston, RN, CNS
o Err is Human...
Building a Safer Health System, Cost of Errors: National averages
Institute of Medicine,2000
Y:An estimated 98,000 One urinary tract infection or pneumonia=$1,600.00
needless deaths a year :One case of venous thrombosis=$5,000.00
caught the nation's Each patient hospitalized receives about 10 doses of
attention. ' medications per day. A typical patient is subject to
Institute for Health Care one medication administration error per hospitalized
Improvement's 100K k day.(barker el al 2002)
lives campaign(2004- — Average additional length of hospitalization associated with a
2006) preventable adverse drug event is 4.6 days,with an increase in
total cost of$5,657(Bele.a 1997
Keeping Patients Safe A "Perfect Storm"
Transforming the Work Environment of Nurses The National Picture
(IOM.2004)
` The baby boom of 1946-
1964 was immediately Re•.e,o•.,• .z.°
Nurses identified as central to patient safety followed by a baby bust
—make u approximately 54%of all U.S.Healthcare which s now producing the
P PP Y smallest pool of entry-level
workers workers since the 1930's j
—Increasing RN time at the bedside by 30 minutes
decreases: 7. In 2010 a national shortage
4.5%for urinary tract infections of up to 1 million RNs is
predicted
4.2%for pneumonia P Buerhaus,JAMA.2000
2.6%for thrombosis
1.8%for pulmonary compromise(K—a Gargan 1998)
1
What this means to us? Nursing at Contra Costa
COTRA COSTA
The State Picture HEAALTH SERVICES
The Local Picture
+r Nurse to patient ratios for $k Average age of our RN=
hospital units 47.7 years
k The supply of RNs is not �t More than 60%of our
G� able to keep up with nurses are retiree eligible
projected population rates in the next 3 5 years
t �Average age of the RN=
47 years Salary alone is not
Shortage will worsen competitive in the bayy
_ each year through 2030, area
and will be deficient by
approximately 73,000
So how can we compete? IHI Initiatives
Yz Transforming Care At the
:�e Staff are committed to our Mission Bedside(TCAB)
- Health Care to ALL,it's not the privilege of a few - Focus on Reliable and Safe Patient-
�r Front line staff drive Quality Care Centered care
- Improve Communications between patient&care team
- Patient-Centered 8 Multidisciplinary
re Become a"Learning Organization" 5 team plans using communication
- Residency Program " boards
- Life-long Learning
- Medication Safety
- Interdisciplinary Care TEAMS
�e Have Fun! - Focus on Patients at Risk for Falls
Contra Costa Featured... The TCAB Team
adViNrim Lisa Massarweh,CNO,Administrative Sponsor
Mananne Bunce-Houston,CNS,Chair
Ria Brandenberg,RN,Medical Nurse Program Manager
_ '!= Rose Zambrano,RN,Surgical Nurse Program Manager
_ E, Tessie Inton,RN,Surgical Charge Nurse
Holly Longmuir,RN,Medical Charge Nurse
- Rosalind Walker,RN,Surgical Staff Nurse
Leadi, Liza Butorac.LVN,Medical Staff Nurse
On Tzvieli,Attending MD,Family Practice,Internal Medicine
--
_-_ _ « Sara Levin,Attending MD,Internal Medicine
__-._--------- :� Donna Garro,RN,Nurse Quality Manager
Karen Finck.PharmD
R James Tatum,Materials Manager
Iz
7
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• Red Slippers
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Aim lo mpru4e patient safety and outcomes to
tj Developed September 2007 identify patients at high risk for falls.
Done every nursing shift
Yx Identify key patients/issues for all staff Every patientseen/screened/,dm ,
3 patients on unit most likely to fall this CCRMC will••placed on Universal Fall
shift Precautions and are evaluated for fall risk.
e t Identify what can you do Fpz,,]S ,
Ex:bed alarms,sitters,vail bed,etc.
Patients identified as a high
3 patients on unit most at risk for Hospital will,•issued"RubySlippers"„ ,alert all staff
_ Acquired Pressure Ulcers , -, ,. care.a
Identify what can you do
• Ex:pressure relieving device,need help to
get patient out of bed,PT/OT referral,etc. re-evaluatedll at
the patient's
Questions? Regional Nurse Network(RN2)
Medication Safety Goals
'6 Call-to-Action supported by Gordon&Betty Moore
Grant(2x2=0)
1. To produce zero medication errors on two units within two
years(by 2009).
2. To use reliability science to ensure a reliable process for
delivering medication.
3. To have nurses spearhead the change process.
4. Currently working on Spread to ALL Medical/Surgical areas
(including ICU,IMCU,telemetry)
3
P '
by is it hard to�giivehe right by is it hard to give the right
medicine 100% of the time? medicine 100% of the time?
M .. —► stair tee"order m ��
rn.mari,t erel�te,ana a,Ren.eg meaiuton �— •
Nursing suHptm mediuton adminig W,—d
DWI mark \
—agaTsl
RH vwt6e+too ofrxh�rder egaina otainal MD oNer(drug.duu, MIF Dgl d<IGI3
route,fieq.,tme)Dnte'time signature nn MD order �— 2M i.Vamrpbors
lintel"venfv"column on IcH of MAR
MnalaY,'V MEDICA710N
Meow ERMA
W i,'lal'Jm g 2
- rams a aeKecauon
NATIONAL
Use at least patient - providing - "No Interruptions" Vest
treatment,or services.
/ ` WHEN PASSING MEDICATIONS,CCRMC NURSES... Goal:
c _
be the patient tneir name and dategt onif birprth; —Create a"cockpit" of safety
... ne<k the patient g regpnnse againg her fD band —Avoid interrupting the
and the MAR before giving a medication;and, nurse for things that can
...document the medication on the MAR immediately.
wait ahalf-hour[phone
CLINIC,LAB,DIAGNOSTIC IMAGING, calls,transfers,"quick"
CARDIOPULMONARY,AND REHAB STAFF... t questions,admissions,
...ask the patient their name and date of birth;and, discharges,etc.]
...check the patient's response against the order :k Studies show interruptions during medication
or requisition. `�`'``' administration lead to med errors.
en it comes to safety,our het ,s in iii ''r Nurses wear a lime-green safety vest while pulling
IIII and administering medications
i
My Experience... So how are we doing?
Nea,e.ne�gaet�
o
4
If you had one wish to
improve care, what would it be? Next Steps...
v,Come back to share future information
x<To move forward will require continued
change including investigating all new
technologies for medication administration
Wouldn't it be nice....
5